Incident investigation·January 16, 2026

On January 16, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 12/18/25. LPA met with Special Operations Director, Kathy Valencia and explained the purpose of the visit. The Licensee reported, on 12/12/25, Resident 1's (R1's) physician changed R1's medication for Pregabalin from one 50mg capsule in the morning to one 75mg capsule in the morning. R1 is with the VA and the facility did not receive the new medication bottle until 12/17/25. On 12/18/25, the med-tech on shift, administered one 50mg capsule in the morning instead of the 75mg capsule. The error was discovered on 12/19/25 by another med-tech. During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. Based on R1's medication list, R1 was required to take one tablet of Pregabalin (75mg) medication daily every morning, and one 75mg tablet at bedtime, however the med-tech administered one 50mg capsule instead. The facility failed to provide R1's medication as prescribed by the physician. According to the Community Support Nurse, the med-tech that administered the wrong medication is no longer employed with the facility and they were unable to get a statement prior to the med-tech leaving. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Special Operations Director, Kathy Valencia and a copy is provided.